Hypertension, orthostatic hypotension and the microvascular complications of diabetes

doi:10.1016/0021-9681(85)90078-5

Journal of Chronic Diseases

Volume 38, Issue 4, 1985, Pages 319-326

Journal of Chronic D...

https://doi.org/10.1016/0021-9681(85)90078-5 Get rights and content

Abstract

Prevalences of hypertension and orthostatic hypotension and their relationship to the microvascular complications of diabetes were assessed in 702 individuals aged 18–74 years, who had been selected as a representative sample of surviving patients with diabetes diagnosed at the Joslin Clinic between 1939 and 1965. In diabetes of short, long and very long duration, hypertension was 1.7, 1.9 and 2.1 times more frequent, respectively, than in the white U.S. population, regardless of gender. The excess frequency of hypertension in short duration diabetes suggests that some etiologic factor is shared by both conditions, while the magnification of the excess with increasing duration could be explained by an effect of diabetes on the kidney. Hypertension without accompanying proteinuria was not associated with retinopathy. Orthostatic hypotension was observed in 12% of the males and 13% of the females. The magnitude of the fall in systolic blood pressure was correlated with age, postprandial blood glucose, supine diastolic blood pressure, and the presence of retinopathy. Patients with proliferative retinopathy had the largest fall in systolic blood pressure.

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Cited by (65)

Diabetes Mellitus: Management of Hypertension in Diabetes
2023, Hypertension: A Companion to Braunwald's Heart Disease
Diabetes mellitus (“diabetes”) and hypertension commonly coexist. They are global public health issues contributing to an enormous burden of cardiovascular disease, chronic kidney disease, and premature mortality and disability. The presence of both conditions has an amplifying effect on risk for micro- and macrovascular complications. The prevalence of diabetes is rising worldwide, and 80% of all cases are found in middle- and low-income countries. Strategies to prevent and effectively manage hypertension and diabetes are complex and require multistakeholder collaboration. In view of the enormous public health impact of both diabetes and hypertension, now is the time for concerted action by engaged groups, including patients, patient advocacy groups, representatives from government, professional organizations, health care delivery systems, and the pharmaceutical industry.
Orthostatic hypotension: Epidemiology, prognosis, and treatment
2015, Journal of the American College of Cardiology
Citation Excerpt :
The diagnosis of initial OH is quite challenging and can only be confirmed by an active standing test with continuous BP monitoring. OH has been traditionally associated with neurodegenerative diseases (1), frailty in elderly patients (35), and chronic heart failure (36), but it is also a frequent finding among patients with hypertension (37,38) and patients with diabetes (39). In published reports, its prevalence ranges between 6% and 35% or more, depending on age and associated comorbidities, showing a strong association with elevated BP (37,38,40,41).
Orthostatic hypotension (OH) is a common cardiovascular disorder, with or without signs of underlying neurodegenerative disease. OH is diagnosed on the basis of an orthostatic challenge and implies a persistent systolic/diastolic blood pressure decrease of at least 20/10 mm Hg upon standing. Its prevalence is age dependent, ranging from 5% in patients <50 years of age to 30% in those >70 years of age. OH may complicate treatment of hypertension, heart failure, and coronary heart disease; cause disabling symptoms, faints, and traumatic injuries; and substantially reduce quality of life. Despite being largely asymptomatic or with minimal symptoms, the presence of OH independently increases mortality and the incidence of myocardial infarction, stroke, heart failure, and atrial fibrillation. In this review, we outline the etiology and prevalence of OH in the general population, summarize its relationship with morbidity and mortality, propose a diagnostic and therapeutic algorithm, and delineate current challenges and future perspectives.
Postural blood pressure changes and associated factors in long-term Type 1 diabetes: Wisconsin Epidemiologic Study of Diabetic Retinopathy
2009, Journal of Diabetes and its Complications
Citation Excerpt :
A prevalence of 16.1% for orthostatic hypotension and 15.2% for orthostatic hypertension was found in persons with long-term Type 1 diabetes. This was consistent with the prevalence found in previous studies involving both Type 1 and 2 diabetes (Krolewski et al., 1985; Wu et al., 1999). We focused on identifying factors that were associated with postural changes in BP in this cohort.
To describe the frequency of orthostatic hypotension and hypertension and associations with risk factors in a cohort of persons with long-term Type 1 diabetes (n=440) participating in the Wisconsin Epidemiologic Study of Diabetic Retinopathy.
Evaluations included detailed medical history, electrocardiography (ECG), and laboratory tests. Blood pressure (BP) was measured in supine and standing positions. Standing decrease in systolic (SBP) or diastolic (DBP) BP of at least 20 or 10 mmHg, respectively, was defined as orthostatic hypotension; increase of SBP from <140 to ≥140 mmHg or DBP from <90 to ≥90 mmHg was defined as orthostatic hypertension.
Prevalence of orthostatic hypotension and orthostatic hypertension was 16.1% and 15.2%, respectively. Some ECG measurements of cardiac autonomic dysfunction were significantly associated with orthostatic hypotension. Association between SBP and orthostatic hypotension and orthostatic hypertension were significant [odds ratio, 1.02 (95% confidence interval, or CI, 1.01–1.05) and 1.02 (95% CI, 1.01–1.04), per 1 mmHg, respectively] after adjusting for confounders. Interaction between SBP and age was observed. SBP was significantly associated with orthostatic hypotension and orthostatic hypertension in people ≤40 years old [1.35 (1.02–1.78) and 1.12 (1.05–1.18), respectively].
Results showed that measurements derived from the ECG can help describe an individual at increased risk of having postural BP changes. Moreover, SBP was associated with postural BP changes among individuals who were <40 years of age with long-term Type 1 diabetes.
Falls as a complication of diabetes mellitus in older people
2006, Journal of Diabetes and its Complications
The aims of this study were to determine the incidence of falls in a group of elderly patients with diabetes and to assess for the prevalence of risk factors for falls in this population.
This is a population-based study with questionnaire-based interviews.
The setting for this study was the London District General Hospital outpatient department.
Seventy-seven patients with diabetes, aged over 65 years, randomly selected whilst attending for general diabetic annual review. Patients with dementia, blindness, and immobility and those who were unable to give informed consent were excluded from this study.
The incidence of falls in the last 12 months was used. Information was collected on the incidence of hypoglycaemic episodes, the presence of other medical conditions, visual impairment, and peripheral neuropathy, the use of medications and walking aids, and HbA1C and blood pressure control.
The incidence of falls was 39%. Falls occurred more frequently in female patients and patients of increasing age. Falls occurred more frequently in patients with poor diabetic control [risk ratio (RR)=7.83 (2.948–20.799), χ² value=6.422]; patients requiring assistance with mobility: for those mobile with a stick [RR=1.839 (1.048–3.227), χ²=4.619]; and those who had previously suffered a stroke [RR=1.929 (1.143–3.257), χ² = 4.615].
We provide evidence that poorly controlled diabetes and conditions associated with complications of diabetes are associated with an increased risk of falling in older people. We recommend early recognition of the multiple causes of falls in the older diabetic patient and prompt referral of this group of patients to a specialist falls clinic.
Orthostatic hypotension is associated with new-onset atrial fibrillation: Systemic review and meta-analysis
2019, Indian Heart Journal
Citation Excerpt :
This mechanism implies that OH may be a harbinger for developing AF. Many conditions are associated with OH including advancing age,39,40 structural heart disease such as aortic stenosis,41 chronic heart failure,22 diabetes,42 and hypertension,43,44; all of which are known AF risk factors. Thus, the presence of OH may serve to raise the suspicion for these underlying comorbidities which are often related to AF.
Orthostatic hypotension (OH) is common among elderly patients. Its presence may herald severe underlying comorbidities and be associated with a higher risk of mortality. Interestingly, recent studies suggest that OH is associated with new-onset atrial fibrillation (AF). However, a systematic review and meta-analysis of the literature has not been performed. We assessed the association between AF and OH through a systematic review of the literature and a meta-analysis.
We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2018. Published prospective or retrospective cohort studies that compared new-onset AF between male patients with and without OH were included. Data from each study were combined using the random-effects, generic inverse-variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals.
Four studies from October 2010 to March 2018 were included in the meta-analysis involving 76,963 subjects (of which 3318 were diagnosed with OH). The presence of OH was associated with new-onset AF (pooled risk ratio 1.48; 95% confidence interval [1.21, 1.81], p?< 0.001; I2 = 69.4%). In hypertensive patients, analysis revealed an association between OH and the occurrence of new-onset AF (OR 1.46; 95% CI [1.27, 1.68], p < 0.001 with I2 = 0).
OH was associated with new-onset AF up to 1.5-fold compared with those subjects without OH. The interplay between OH and AF is likely bidirectional.
Diabetes and hypertension: The bad companions
2012, The Lancet
Citation Excerpt :
In people without diabetes, the prevalence of untreated hypertension in women is less than that of men until they reach 55–64 years of age, when the prevalence reaches that of men and then begins to increase at a faster rate. In people with diabetes, the prevalence of untreated hypertension in women reaches that of men about one decade earlier (ie, between 45 and 54 years).9 In patients with type 2 diabetes, sex (male), family history, age, and BMI continue to be independent risk factors for the high blood pressure;10 additionally, duration of diabetes adds to risk, whereas good renal function (measured by estimated glomerular filtration rate) is protective.
High blood pressure is reported in over two-thirds of patients with type 2 diabetes, and its development coincides with the development of hyperglycaemia. Many pathophysiological mechanisms underlie this association. Of these mechanisms, insulin resistance in the nitric-oxide pathway; the stimulatory effect of hyperinsulinaemia on sympathetic drive, smooth muscle growth, and sodium–fluid retention; and the excitatory effect of hyperglycaemia on the renin–angiotensin–aldosterone system seem to be plausible. In patients with diabetes, hypertension confers an enhanced risk of cardiovascular disease. A blood pressure of lower than 140/85 mm Hg is a reasonable therapeutic goal in patients with type 2 diabetes according to clinical trial evidence. People with controlled diabetes have a similar cardiovascular risk to patients without diabetes but with hypertension. A renin–angiotensin system blocker combined with a thiazide-type diuretic might be the best initial antihypertensive regimen for most people with diabetes. In general, the positive effects of antihypertensive drugs on cardiovascular outcomes outweigh the negative effects of antihypertensive drugs on glucose metabolism.

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Original articleHypertension, orthostatic hypotension and the microvascular complications of diabetes

Abstract

J Chron Dis

J Chron Dis

Diabetes

Hypertension and diabetes mellitus

Q J Med

Some aspects of hypertension in diabetes mellitus

JAMA

Arterial pressure in clinically apparent diabetes

Diabete Metab

Hypertension: The major risk factor in juvenile-onset insulin-dependent diabetics

Diabetes

The natural history of diabetes. I. Mortality

Diabetes

Statistical Methods in Medical Research

Epidemiology of diabetes mellitus

Diabetes and heart disease: periodic health examination programs

Am J Publ Health

Risk factors in coronary artery disease, hypertension and diabetes

Am J Med Sci

Original article
Hypertension, orthostatic hypotension and the microvascular complications of diabetes